Armando Peixoto

Risk factors associated with refractoriness to esophageal dilatation for benign dysphagia.

Background Benign esophageal strictures need repeated dilatations to relieve dysphagia. Literature is scarce on the risk factors for refractoriness of these strictures. Aim This study aimed to assess the risk factors associated with refractory strictures. Materials and methods This is a retrospective study of patients with benign esophageal strictures who were referred for esophageal dilatation over a period of 3 years. Results A total of 327 esophageal dilatations were performed in 103 patients; 53% of the patients reported dysphagia for liquids. Clinical success was achieved in 77% of the patients. There was a need for further dilatations in 54% of patients, being more frequent in patients with dysphagia for liquids [78 vs. 64%, P=0.008, odds ratio (OR) 1.930], in those with caustic strictures (89 vs. 70%, P=0.007, OR 3.487), and in those with complex strictures (83 vs. 70%, P=0.047, OR 2.132). Caustic strictures, peptic strictures, and complex strictures showed statistical significance in the multivariate analysis. Time until subsequent dilatations was less in patients with dysphagia for liquids (49 vs. 182 days, P<0.001), in those with peptic strictures (49 vs. 98 days, P=0.004), in those with caustic strictures (49 vs. 78 days, P=0.005), and in patients with complex strictures (47 vs. 80 days P=0.009). In multivariate analysis, further dilatations occurred earlier in patients with dysphagia for liquids [hazard ratio (HR) 1.506, P=0.004], in those with peptic strictures (HR 1.644, P=0.002), in those with caustic strictures (HR 1.581, P=0.016), and in patients with complex strictures (HR 1.408, P=0.046). Conclusion Caustic, peptic, and complex strictures were associated with a greater need for subsequent dilatations. Time until subsequent dilatations was less in patients with dysphagia for liquids and in those with caustic, peptic, and complex strictures.

Efeito da temperatura na síntese de óxidos hidratados de nióbio e zircônio e adsorção de íons Ag+ e Pb2+

This work reports the digestion temperature effect of precipitating agent on the physical and chemical characteristics of Nb2O5.nH2O and ZrO2.nH2O. The compounds were obtained by homogeneous solution precipitation method with thermal decomposition of (NH4)2CO3 at 45 oC and 90 oC. The X-ray diffraction analysis showed crystalline materials with interlamelar space for both Nb2O5.nH2O, whereas ZrO2.nH2O is amorphous. By thermal analysis a similar hydration grade was observed for all materials. The Langmuir adsorption isotherms show that the materials prepared at 90 oC, in both cases, have the best results.

Nutrition in Chronic Liver Disease

Protein-calorie malnutrition is a transversal condition to all stages of chronic liver disease. Early recognition of micro or macronutrient deficiencies is essential, because the use of nutritional supplements reduces the risk of complications. The diet of patients with chronic liver disease is based on a standard diet with supplements addition as necessary. Restrictions may be harmful and should be individualized. Treatment management should aim to maintain an adequate protein and caloric intake and to correct nutrient deficiencies. The large majority of patients with grade I/II hepatic encephalopathy can tolerate a regular diet. Protein restriction can aggravate malnutrition and is not recommended, except in cases of hepatic encephalopathy unresponsive to optimized therapy.

Impact of Infliximab and Cyclosporine on the Risk of Colectomy in Hospitalized Patients with Ulcerative Colitis Complicated by Cytomegalovirus-A Multicenter Retrospective Study.

Background: Cytomegalovirus (CMV) is frequently detected in patients with ulcerative colitis (UC). The impact of CMV infection on the outcome of UC exacerbation remains unclear. The benefit of combining antiviral with anti-inflammatory treatment has not been evaluated yet. The aim of this study was to compare the outcome of CMV-positive hospitalized patients with UC treated with antiviral therapy either alone or combined with salvage anti-inflammatory therapy (infliximab [IFX] or cyclosporine A [CsA]). Methods: This was a multicenter retrospective study of hospitalized CMV-positive patients with UC. The patients were classified into 2 groups: antiviral—if treated with antivirals alone; combined—if treated with both antiviral and anti-inflammatory therapy. The outcomes included the rate of colectomy in both arms during the course of hospitalization and after 3/12 months. Results: A total of 110 patients were included; 47 (42.7%) patients did not receive IFX nor CsA; 36 (32.7%) received IFX during hospitalization or within 1 month before hospitalization; 20 (18.1%) patients received CsA during hospitalization; 7 (6.4%) were exposed to both IFX and CsA. The rate of colectomy was 14.5% at 30 days, 20.0% at 3 months, and 34.8% at 12 months. Colectomy rates were similar across treatment groups. No clinical and demographic variables were independently associated with the risk of colectomy. Conclusions: IFX or cyclosporine therapy is not associated with additional risk for colectomy over antiviral therapy alone in hospitalized CMV-positive patients with UC.

Association between Polymorphisms in Antioxidant Genes and Inflammatory Bowel Disease

Inflammation is the driving force in inflammatory bowel disease (IBD) and its link to oxidative stress and carcinogenesis has long been accepted. The antioxidant system of the intestinal mucosa in IBD is compromised resulting in increased oxidative injury. This defective antioxidant system may be the result of genetic variants in antioxidant genes, which can represent susceptibility factors for IBD, namely Crohn’s disease (CD) and ulcerative colitis (UC). Single nucleotide polymorphisms (SNPs) in the antioxidant genes SOD2 (rs4880) and GPX1 (rs1050450) were genotyped in a Portuguese population comprising 436 Crohn’s disease and 367 ulcerative colitis patients, and 434 healthy controls. We found that the AA genotype in GPX1 is associated with ulcerative colitis (OR = 1.93, adjusted P-value = 0.037). Moreover, we found nominal significant associations between SOD2 and Crohn’s disease susceptibility and disease subphenotypes but these did not withstand the correction for multiple testing. These findings indicate a possible link between disease phenotypes and antioxidant genes. These results suggest a potential role for antioxidant genes in IBD pathogenesis and should be considered in future association studies.

Cholangitis after endoscopic retrograde cholangiopancreatography: a rare complication?

In our experience, post-ERCP acute cholangitis developed in approximately 5% of cases with a not negligible mortality of nearly 30% in spite of antibiotic therapy. Analytical factors can help to identify the most serious cases that could benefit from a more aggressive approach.

Anal condylomas: predictors of recurrence and progression to high-grade dysplasia/carcinoma in situ

Condyloma acuminatum is caused by human papilloma virus (HPV) infection. Individuals with condylomata acuminata are at an increased risk for anogenital cancers, mainly anal condylomas with dysplasia are precursors of anal squamous cell carcinoma. There are over 70 distinct HPV subtypes; approximately 35 types are specific for the anogenital epithelium and have varying potentials to cause malignant change, such as cervical or anal cancer (1).

How SpyGlass™ May Impact Endoscopic Retrograde Cholangiopancreatography Practice and Patient Management

Introduction: Cholangiopancreatoscopy with SpyGlass™ Direct Visualization System (SGDVS) is being used in specialized centers for improving the sensitivity of endoscopic retrograde cholangiopancreatography (ERCP) in patients with indeterminate pancreatobiliary strictures (PBS). The aims of this study were to report our initial experience with SGDVS in the evaluation of indeterminate PBS, and discuss the improvements of ERCP brought by this technique in our center. Methods: The usefulness of SGDVS in patients with indeterminate PBS (defined after nondiagnostic previous ERCP with brush cytology) was evaluated in a prospective observational cohort study conducted at a single tertiary biliopancreatic unit. The accuracy of diagnosis by the SGDVS visual findings, SGDVS-guided biopsy, technical success, image quality, change in patient management after the procedure, and complication rate were assessed. Results: In our single-center cohort, there were 13 SGDVS procedures for evaluating indeterminate PBS. Technical success, defined by the ability to progress with the SpyScope to the target lesion, was achieved in all the cases. The diagnostic accuracy of visual findings (87.5%) was superior to SGDVS-guided biopsy (55%). In 11 (85%) procedures, the image quality was considered good. The procedure permitted exclusion of malignancy and avoiding surgery in 9 patients (69%). There were no complications during the procedures. However, in the post-procedure monitoring, 3 patients developed acute pancreatitis (19%) and 2 patients developed acute cholangitis (13%). Conclusion: The SGDVS can be considered useful in the context of indeterminate PBS. The intervention is associated with high procedural success and alters clinical outcome compared to conventional approaches.

Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound: To Be One Traveler in Converging Roads

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were initially introduced into the world of gastroenterology as purely diagnostic procedures. With progressive evolution of intervention, both these techniques conquered fields in the treatment of many conditions that had once been exclusively surgical domains. Nowadays, more and more clinical situations have an indication to perform both EUS and ERCP, and these two techniques are frequently required at the same time for the same patient. More than competitors, ERCP and EUS are truly complementary, with great ability for mutual aid. They share their main indications, equipment, accessories, and main technical gestures. Objectives and Methods: We review the major indications to perform both techniques, sequentially or complementarily, describe the common things that these two techniques essentially share, and discuss the ERCP-EUS single session. Also, the issues of learning curves and education of upcoming biliopancreatic endoscopists are highlighted. Conclusion: In recent years the complementation between ECRP and EUS has been growing both from a diagnostic and a therapeutic point of view, allowing optimization of the use of these techniques and the creation of a more systematized approach of patients with biliopancreatic pathology. Endoscopists with experience in both techniques will be increasingly important, suggesting a parallel formation in the training plans of future endoscopists with interest in the area.

Eosinophilic ileocolitis due to Enterobius vermicularis infection: a rare cause of anemia.

Dear Editor: The authors report the case of a 38-year-old male patient with Down’s syndrome. He was brought to a gastroenterology consultation due to an iron-deficient anemia of unknown etiology. A previous fecal blood test was positive in two of six samples. In this context, it was proposed to perform a diagnostic colonoscopy which was accepted by the patient and his caregivers. During the examination, the presence of small superficial erosions in the right colon, as well as numerous pinworms, more abundant in the cecum, and also ulceration of the ileocecal valve was seen. Multiple biopsies were then performed in the ileocecal valve whose histology revealed the presence of an intense inflammatory response with a predominance of eosinophils. The patient was subsequently treated with an anthelmintic agent, with clinical improvement and resolution of the anemia. Ileocolitis due to Enterobius vermicularis has been reported in the literature as early as 1919, but it is not widely recognized as a cause of intestinal inflammatory disease. Humans are the only natural host. E. vermicularis, commonly known as pinworm or threadworm, is responsible for a widespread parasitic infection estimated to affect up to 209 million people worldwide. Around 4 to 28 % of children worldwide are reported to be infected [1]. Pinworms measure approximately 10 mm in length, and the terminal ileum, cecum, and ascending colon are the usual habitats. The most common mechanism of infestation is through fecal oral route (autoinfection) via contaminated fingers. Contaminated food or utensils can also be responsible for dissemination. Less frequently, the parasite eggs can hatch in the anus and infect the colon in a retrograde fashion (retroinfection) [2]. The pathophysiology of Enterobius ileocolitis is not well understood. Controversy exists as to whether the worm is responsible for mucosal ulceration or merely takes up residence in preexisting ulcerated mucosa. Some investigators have hypothesized that an immediate hypersensitivity reaction to parasite secretions or surface antigens accounts for the eosinophilic infiltrate [3]. The vast majority of the infested population is unaware of the parasite because of the lack of symptoms. Themost common symptom is pruritus in the perianal region, but infestation may also present with ileocolitis, enterocutaneous fistula, urinary tract infection, mesenteric abscesses, salpingitis, and appendicitis [4]. The presence of pinworms in the appendix has been shown to cause symptoms mimicking appendicitis or appendiceal Bcolic^ but frequently without any histological evidence of acute inflammation [1]. Enterobius ileocolitis should be included on the list of diseases that can cause bowel wall thickening due to eosinophilic infiltrates. Awareness of this entity is important because Enterobius ileocolitis is easily curable with proper treatment.